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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DIiLCARATION
<br />I hcrcbt ltflftn undcr pcnrlry ol pcrJury lhtrl ! onr cxe.rpl Lorn rhc Conrr.cros l-icne bs fn rhc rollowirlS rcisotr (Scc.?011.5
<br />Busirrcss aRl Profc$ion Codc): Any Ciry o! Counry $hnh rqltcs a ltmn h ..n{rucr. alrcr, imprevc. dcnnlish nr rcpat otry
<br />\rrucrurc. prnrr{, ih issrd.c. al{, r.qun i rh. lpplicanr r.r \nch lf,nnn b fiL! siSnql s.rcrN thlt hcor sh€ i\ lircitcd Nrsuani
<br />h rhc lft,vsn,nr oi rhc contrrctols Licc,sd tjs (Chrprcr 9, ConmEncins *irh Sccri.n ?Ux) o, Division I oflhc Eusincss ond
<br />Pn,rcsridrs Codc) or rllll hcorshc ncxcmpl lhcrcaronand rhclnr\is for lh. slkscd.xcnlrirn Anyviolatl'nofSccthn?Oll5by0ny
<br />appli.nnrlu!Ir.mirslhjr.rrrhc srtlicanr tu acivilpcnalryornnr fl crhan fivc hundrc! dollan (S500).
<br />-1.
<br />rs owncr oI lhc t,otcny. or m, cnrrlorlc\ wirh wascs as lhct ek conpcnsdli.n, will do rh. wo* md rtf, stllrluc is rcl
<br />i,rcndcn o. ontred for eh t5( 7(x4, aosimss and ft,ac*ion\ Gxtc Thc Coftacbls Li.cnsc Li* docs nol aml, ro ai owmr or
<br />lhc ptupcdy wh. builds or imEolcs lh.6tr. and qk) des su.h w,* himscllor hcsclfor rhn lBh hh or h.r.wncntployc.l.
<br />rolidcd rhar such imnn*mnk .B rei inrcndcd or oiIdcrl iirr slc li howcrcr. rh. boildiu or impmvcrEnr is sold wirhin onc y.r
<br />oacomphrion- $c OeE, Build.r *ill hrrt rtr buni.n of poving rhlr ltor $c dil n, tdu or iriprctr fic IrIEny for rlE Plrln{ ol'
<br />I- nsowncrolthe popddr.,ncrclu\ivcly.onrding sirh li.enlcdconr k,N to con(Dcl lhc p(+cl (Ss.' 7044, Bdli'lcs
<br />rtu ft)fNirC.dc: TheCotrrscttr s l-icctr\c l-asdocs nor ip|lyro sno*ncr orrii,t ywho build\ or mlolcs rhcrcon.
<br />dnd who .onhcr\r.rsu.h Eolc.B with ! Contmcro.( o liensd pururnr ro thc Cont.lc'ois l,icen\c tr*).
<br />I r'n .nrn' unds Serion . B & PC. fo' lhn rcr\"n
<br />D . _. o*tr..
<br />woRxFR\' ( (lMPF]\SAII()N
<br />!ECI.AtrAII!'N
<br />I tcrcht lfirmundcr lcnally of Frjory oft orih. rolbwing ddbrariDn\
<br />IhDvrMdsill ai' ninrCdnifr.rcolCotrsctrruSclllNurttrsorkLJJconll4nsllion.oi prolidcdf{trhrS(rionlTO0ofrhc
<br />I rhor CGic. li,r rhe !.rlbndncc of rh. w.rk fd which rh. p.rmir i\ irsu.rl
<br />_l hrrc lnd willnrinrain sork.m .o'npcnsarbn insurnn... !s r.quncd hySciion l?00of lhc tihorG)de. for rl[ ri.rfntucc ol
<br />rhc wolk larwhichrhn pcm a\ issu.d Mywork.n .o,np.ns.rion insutuncc .aricr ntu lblicynnmbcr scl
<br />Ebuctl rvtaat*<-eeiot lqog b- /?
<br />I ccnilyrhrlirrhc lcrloirn0nccorrhc wort lor $hichrhi\Firrir i\ i\\ued- I \hrll nor cnDby anyl.N{ hnfl, m Nr
<br />s nrhccomsrbJc.rrorhcwo cdonlxnrarn,nlrssofcalinm,a.lud.!rccrharifIshouldh.cotrEsuh]cdt'lhc
<br />workc'i co'nFn\ari{,npxrvili,,nsolSc.rionl70OoIth.Lill,(idc.Isl LlirnhwilhonDlywirhlhxcl)trrisions
<br />WAINING F,ilurc ro scurc *orkcrs' comr(nsnrhn covcmsc i\ unhwrul, md rhsll subjc.r nn cmtl.F lo ri,nird r.trrltics rnd
<br />.ivil lincs ut k' om hundrcd lhousrnd dolhn (310(oddnio. ro rh. c.{ or.omp.ns on. dlnE8cs rs lrovacd for lhc
<br />I1 tb
<br />DECLAAA.IIA!
<br />I hcEby atltnr uder pcdltyolp.rjury thar I dn li(n$d und.r povision ofCholts 9 (con1ftncn{ vhh s..tion ?0(x)) ofDivhion 3
<br />ol rh. Ausirc$ ud Pmfc$ions C.d.- aid my liccn\d ic i. ful tnre and cfldr,
<br />qq lab iLl
<br />t?,
<br />!:ONiIBUSIX}N.LINIIIiAAGEN.CI
<br />I hcEb, ailirn !ndc! Fn,hy or p.rjury d rhcrc h n con{dction lcndins sscncy for rh. pcrrommc of rhc work for $hth rhis Frnn i\
<br />isrucd(S( 3097. Civ. C.)
<br />AIILIIANIIIEI;I,AMIIO!
<br />I lmby afiinn undcr pcn.lty olpcrjlry 6nc.ilhc roll,uing dc.l,di,cns:
<br />Dc'tulirn,n P.rdirs Ash.sos Notifi.arion Fcdcrul Rcgularions (-lirlc 40. Pan6)
<br />R.qxircd t tr.r oI Nodff,otion
<br />-l
<br />ccdifyrhrr rhc ndcrrlrclnhnn,s tsdl,.! r\hc{o\.Likrnlrrc nor anplicrhLr) lhi\ pmr.cr
<br />l..nirrrhrrllulcrcM rhisipplic{lior ora(nldh rhc rhovc inlnrnLrid n.otrdr lrEL\bconDlyuirhtrllCirrrDdCoutrrt
<br />ordinan.cs nnd Srrrc ljs\ EbhnS to if!.,{r{rudi()n. dhc'ehyrurhtri7.r.frc\rrrnri
<br />rl.drc nEoli,)ncJ Frcpcny in
<br />,\pplirfltrt or Agenl SiBnnl 5. 1\,r)oVlJ2C
<br />\c\ ofrhn Cnv andCounrv'<\q'l
<br />o.,. "'t t I
<br />(u
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Lite Satety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Torqueino
<br />Sub-Panels
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)E '')V.^,.o @)
<br />Ceilinqs (Hard & Solfit Rouoh
<br />Ceilinqs (T-Bar Rouqh)
<br />ltrleter Release
<br />Rouoh
<br />Service lVleter
<br />FINAL LbVn/tx1 lrilrtllY lfi-/
<br />Notes, Remarks, Etc.
<br />Translormers
<br />Air Conditioners
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